Decision fatigue in hospital medicine: A scoping review

Abstract

BACKGROUND: Decision fatigue describes the erosion of decision-making capacity as a consequence of the repeated acts of decision making. The phenomenon has been detected in ambulatory settings with higher rates of inappropriate antimicrobial and opiate prescribing and lower rates of cancer screening associated with appointments that occur later in the day. As hospital medicine is acknowledged to be a cognitively intense specialty, we decided to explore decision fatigue in hospital medicine. METHODS: As a relatively unexplored concept, we undertook a scoping review to understand what is known about decision fatigue in hospital medicine. All studies including healthcare workers in acute care settings and exploring the concepts of decision fatigue, cognitive burden and/or fatigue were included. Conceptually related studies of sleep deprivation, shift work, Circadian disruption, and excessive workloads with actual or theoretical paths of causality related to patient outcomes were also included. RESULTS: Our preliminary search revealed fifteen studies that met our inclusion criteria. No study specifically included hospitalists. Most studies described the concept among nurses, residents, and/or emergency department physicians. The outcomes studied were diverse and included self reported perceptions (e.g. perceived impact on patient care) and validated scales to measure fatigue and psychomotor performance. Fewer studies investigated clinical decisions such as the use of consultations, imaging and disposition decisions through the emergency department. Mitigating circumstances such as age, experience, responsibilities outside the hospital (e.g. having children) were infrequently described. CONCLUSIONS: While hospital medicine's fast pace, multitasking, fragmentation between clinicians and interruptions make it susceptible to decision fatigue, the concept remains under-explored in hospital medicine. The lack of consistent terminology complicates the evaluation of a phenomenon which ultimately is the culmination of individual, patient, work system and work environment factors. There is a need to detect and defuse the impact of decision fatigue in hospital medicine.